197607017-4-26-2022-31-AS-JMAZ-CDUSLJ-20220426135821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607017
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:59:50 PM

Document Has Been Signed on 04/26/2022 01:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,		FACILITY NUMBER:	197607017
ADMINISTRATOR:	ROMULUS KENEZ		FACILITY TYPE:	740
ADDRESS:	8821 ZELZAH AVENUE		TELEPHONE:	(818) 885-0999
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	04/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Diana Kenez		TIME COMPLETED:	02:10 PM

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On 04/26/22 at 12:20 p.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conducted an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA’s temperature was taken. LPA Martinez later met with Administrator Diana Kenez and the purpose of the visit was explained. A physical tour of the facility was conducted and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. There is a separate closet space for the laundry area which is kept locked. Smoke/carbon monoxide detectors are located throughout the facility and are hardwired. Smoke and carbon monoxide detectors were tested and appear to be functional. Fire extinguisher has a service date of 10/05/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 76.0 F. Resident Rooms: Facility has eight (8) bedrooms which of six (6) are designated for resident use. All eight (8) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting. Bathrooms: There are four (4) bathrooms in the facility of which three (3) are designated for client's use. LPA observed all bathrooms to be clean and free of any hazards. Grab bars and non-skid mats were observed. The hot water was tested and measured at 137.1 F.

(Continue on 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,	FACILITY NUMBER: 197607017
	VISIT DATE: 04/26/2022

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Garage: There is an attached garage that is used for additional storage. This area is inaccessible to residents. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a body of water which is kept locked and inaccessible to residents.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited See 809-D. Report signed and delivered. Appeal rights delivered. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/26/2022 01:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EVENING GRACE RESIDENTIAL FACILITY FOR ELDERLY,	FACILITY NUMBER: 197607017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/27/2022 Section Cited	1 2 3 4 5 6 7	87303(e)(2) Maintenance and Operation Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation water measured at 137.1 F, which poses an immediate Health, Safety or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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